1
|
Quinn KM, Runge LT, Griffiths C, Harris H, Pieper H, Meara M, Poulose B, Narula V, Renton D, Collins C, Harzman A, Husain S. Laparoscopic vs robotic inguinal hernia repair: a comparison of learning curves and skill transference in general surgery residents. Surg Endosc 2024; 38:3346-3352. [PMID: 38693306 DOI: 10.1007/s00464-024-10860-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/10/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND There is no consensus on whether laparoscopic experience should be a prerequisite for robotic training. Further, there is limited information on skill transference between laparoscopic and robotic techniques. This study focused on the general surgery residents' learning curve and skill transference within the two minimally invasive platforms. METHODS General surgery residents were observed during the performance of laparoscopic and robotic inguinal hernia repairs. The recorded data included objective measures (operative time, resident participation indicated by percent active time on console or laparoscopy relative to total case time, number of handoffs between the resident and attending), and subjective evaluations (preceptor and trainee assessments of operative performance) while controlling for case complexity, patient comorbidities, and residents' prior operative experience. Wilcoxon two-sample tests and Pearson Correlation coefficients were used for analysis. RESULTS Twenty laparoscopic and forty-four robotic cases were observed. Mean operative times were 90 min for robotic and 95 min for laparoscopic cases (P = 0.4590). Residents' active participation time was 66% on the robotic platform and 37% for laparoscopic (P = < 0.0001). On average, hand-offs occurred 9.7 times during robotic cases and 6.3 times during laparoscopic cases (P = 0.0131). The mean number of cases per resident was 5.86 robotic and 1.67 laparoscopic (P = 0.0312). For robotic cases, there was a strong correlation between percent active resident participation and their prior robotic experience (r = 0.78) while there was a weaker correlation with prior laparoscopic experience (r = 0.47). On the other hand, prior robotic experience had minimal correlation with the percent active resident participation in laparoscopic cases (r = 0.12) and a weak correlation with prior laparoscopic experience (r = 0.37). CONCLUSION The robotic platform may be a more effective teaching tool with a higher degree of entrustability indicated by the higher mean resident participation. We observed a greater degree of skill transference from laparoscopy to the robot, indicated by a higher degree of correlation between the resident's prior laparoscopic experience and the percent console time in robotic cases. There was minimal correlation between residents' prior robotic experience and their participation in laparoscopic cases. Our findings suggest that the learning curve for the robot may be shorter as prior robotic experience had a much stronger association with future robotic performance compared to the association observed in laparoscopy.
Collapse
Affiliation(s)
- Kristen M Quinn
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St., Charleston, SC, 29425, USA.
| | - Louis T Runge
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St., Charleston, SC, 29425, USA
| | - Claire Griffiths
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hannah Harris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Heidi Pieper
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael Meara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ben Poulose
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vimal Narula
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David Renton
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Courtney Collins
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Syed Husain
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
2
|
Lusty A, Alexanian J, Kitto S, Wood T, Lavallée LT, Morash C, Cagiannos I, Breau RH, Raîche I. How Surgeons Think to Avoid Error: A Case Study of the Neurovascular Bundle Sparing During a Robotic Prostatectomy. JOURNAL OF SURGICAL EDUCATION 2024; 81:570-577. [PMID: 38490802 DOI: 10.1016/j.jsurg.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To illustrate how experts efficiently navigate a "slowing down moment" to obtain optimal surgical outcomes using the neurovascular bundle sparing during a robotic prostatectomy as a case study. DESIGN A series of semistructured interviews with four expert uro-oncologists were completed using a cognitive task analysis methodology. Cognitive task analysis, CTA, refers to the interview and extraction of a general body of knowledge. Each interview participant completed four 1 to 2-hour semistructured CTA interviews. The interview data were then deconstructed, coded, and analyzed using a grounded theory analysis to produce a CTA-grid for a robotic prostatectomy for each surgeon, with headings of: surgical steps, simplification maneuvers, visual cues, error/complication recognition, and error/complication management and avoidance. SETTING The study took place at an academic teaching hospital located in an urban center in Canada. PARTICIPANTS Four expert uro-oncologists participated in the study. RESULTS Visual cues, landmarks, common pitfalls, and technique were identified as the 4 key components of the decision-making happening during a slowing down moment in the neurovascular bundle sparing during a robotic prostatectomy. CONCLUSION The data obtained from the CTA is novel information identifying patterns and cues that expert surgeons use to inform their surgical decision-making and avoid errors. This decision-making knowledge of visual cues, landmarks, common pitfalls and techniques is also generalizable for other surgical subspecialties. Surgeon educators, surgical teaching programs and trainees looking to improve their decision-making skills could use these components to guide their educational strategies.
Collapse
Affiliation(s)
- Avril Lusty
- University of Ottawa, Queen's University, Ottawa, Ontario, Canada.
| | - Janet Alexanian
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Simon Kitto
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Tim Wood
- Department of Medical Education, Director, Assessment and Evaluation, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Luke T Lavallée
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chris Morash
- Division of Urology, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute/University of Ottawa, Ontario, Canada
| | - Isabelle Raîche
- Department of Surgery, University of Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Pakkasjärvi N, Anttila H, Pyhältö K. What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework. BMC MEDICAL EDUCATION 2024; 24:119. [PMID: 38321437 PMCID: PMC10848354 DOI: 10.1186/s12909-024-05068-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/17/2024] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes. BACKGROUND Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies. METHODS A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents. RESULTS Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored. CONCLUSION The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.
Collapse
Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland.
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden.
| | - Henrika Anttila
- Faculty of Educational Sciences, University of Helsinki, Helsinki, Finland
| | - Kirsi Pyhältö
- Faculty of Educational Sciences, University of Helsinki, Helsinki, Finland
- Centre for Higher and Adult Education, Faculty of Education, Stellenbosch University, Stellenbosch, South Africa
| |
Collapse
|
4
|
Keuning MC, Lambert B, Nieboer P, Huiskes M, Diemers AD. Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review. JOURNAL OF SURGICAL EDUCATION 2024; 81:93-105. [PMID: 37838573 DOI: 10.1016/j.jsurg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/24/2022] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed. BACKGROUND Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence. METHODS A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included. RESULTS Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role. CONCLUSIONS This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.
Collapse
Affiliation(s)
- Martine C Keuning
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Bart Lambert
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition Groningen, University of Groningen, Groningen, The Netherlands
| | - Agnes D Diemers
- Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
5
|
Morrill C, Hardin J, Steiman J. Perioperative Reflection: An Understudied Yet Common Practice Among Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2023; 80:428-433. [PMID: 36463008 DOI: 10.1016/j.jsurg.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Directed reflection, a descriptive, analytical, and critical reasoning process, has been implemented in several professional fields as a method of developing expertise. In surgery, investigation of reflection has been limited. To date, we are unaware of any study that has sought to define or characterize the independent reflective practices of surgical trainees. In this small pilot study, we characterize the independent operative reflection activities among surgical residents at a single academic institution. DESIGN An unvalidated survey was developed through cognitive interviews and pilot testing to assess 5 aspects of operative reflection. An IRB approved electronic survey was developed and distributed to all general surgery residents at an academic institution. Responses were divided by post-graduate year into junior residents (JR; PGY 1-3) and senior residents (SR; PGY 4-5). RESULTS A response rate of 46% (23/50) was attained. All respondents self-identified as operative reflectors. Three primary methods of reflection were identified: mental, written, and oral. Mental reflection was the primary reflection method of 75% of our respondents as identified by step-by-step mental rehearsal, internal narration, and question series. Reflection was practiced everyday by 42% of respondents. Topics of reflection focused on weaknesses (50%), self-improvement (35%) and judgment (15%). Several respondents (57%) indicated that reflection-based learning tools would be useful. No statistically significant changes in the method or frequency were established between junior and senior residents (p = 0.378, p = 0.464, respectively). Variation in mental reflection activities among JR and SR groups were found (p = 0.029, p = 0.00004, respectively). CONCLUSIONS The enduring role of reflection in experiential learning has been established in many professional fields but remains under-utilized in surgical education. Our study suggests surgical residents reflect independently of curriculum in individual and categorizable ways. Further investigation is required to adequately characterize reflective habits of the surgical resident and evaluate its impact on competency.
Collapse
Affiliation(s)
- Christian Morrill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Jackson Hardin
- Statistical Consulting Center, Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer Steiman
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
6
|
Rostolis R, Temperley HC, Larkins K, Burgess A, Proud D, Mohan H. Exploring the educational value of the general surgical outpatient clinic: a systematic review. GLOBAL SURGICAL EDUCATION : JOURNAL OF THE ASSOCIATION FOR SURGICAL EDUCATION 2023; 2:28. [PMID: 38013869 PMCID: PMC9887554 DOI: 10.1007/s44186-023-00106-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/28/2022] [Accepted: 01/16/2023] [Indexed: 02/01/2023]
Abstract
Purpose Optimising opportunities for exposure and learning in the clinical environment is a priority for surgical education. The surgical outpatient clinic provides a setting for engaging with the patient journey while gaining essential surgical knowledge and skills. This systematic review seeks to determine the role of the outpatient clinic in current surgical education for multiple levels of learners and identify strategies to improve educational utility. Methods A systematic search strategy was conducted across Medline (OVID), Embase, PubMed, and Web of Science databases according to PRISMA guidelines. A comprehensive grey literature search for evaluation of international postgraduate surgical curricula was also performed. Publications were included if they discussed or utilised the general surgical outpatient clinic in an educational context. Results Nine publications were included in this review. Educational interventions in a surgical outpatient clinic setting were discussed in three publications and two publications presented observational data relating to educational opportunities in the surgical outpatient clinic. Four postgraduate surgical curricula outlined the current approaches to surgical education in the outpatient clinic setting. Assessment of included studies by Kirkpatrick level of evidence highlighted that included studies did not investigate high-order educational outcomes. Thematic analysis of curricula was utilised to build a common set of learning outcomes. Conclusions Educational interventions were found to improve learning outcomes, particularly those that facilitated active student participation. Postgraduate surgical curricula utilise the surgical outpatient clinic and recognise its importance in surgical training through the implementation of outpatient-based learning objectives which serve as fundamental components of training. Common learning objectives can be used to direct further research into the efficacy of this educational context. Supplementary Information The online version contains supplementary material available at 10.1007/s44186-023-00106-8.
Collapse
Affiliation(s)
- Renee Rostolis
- Department of Colorectal Surgery, Austin Health, Heidelberg, VIC Australia
- The University of Melbourne, Melbourne, VIC Australia
| | | | - Kirsten Larkins
- The University of Melbourne, Melbourne, VIC Australia
- Peter MacCallum Cancer Centre, Melbourne, VIC Australia
| | - Adele Burgess
- Department of Colorectal Surgery, Austin Health, Heidelberg, VIC Australia
- The University of Melbourne, Melbourne, VIC Australia
| | - David Proud
- Department of Colorectal Surgery, Austin Health, Heidelberg, VIC Australia
- The University of Melbourne, Melbourne, VIC Australia
| | - Helen Mohan
- Department of Colorectal Surgery, Austin Health, Heidelberg, VIC Australia
- The University of Melbourne, Melbourne, VIC Australia
- Peter MacCallum Cancer Centre, Melbourne, VIC Australia
| |
Collapse
|
7
|
De Mol L, Vangeneugden J, Desender L, Van Herzeele I, Konge L, Willaert W. Using an application to measure trainees' procedural knowledge before chest tube insertion. Postgrad Med J 2022:7150860. [PMID: 37137554 DOI: 10.1136/postgradmedj-2022-141580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE STUDY To collect validity evidence for the chest tube insertion (CTI) test mode on the medical simulation application Touch Surgery. This was done by using Messick's contemporary framework. METHODS Novice, intermediate and experienced participants provided informed consent and demographic information. After familiarisation with the application, they completed the CTI test mode. Validity evidence was collected from four sources: content, response process, relation to other variables and consequences. A post-study questionnaire with 5-point Likert scales assessed the perceived realism, relevance and utility of the assessment. Mean scores of the three groups were compared. RESULTS A total of 25 novices, 11 intermediates and 19 experienced participants were recruited. Content evidence was collected by an expert in CTI and was based on published literature and guidelines. All users were familiarised with the application, and received standardised instructions throughout the test. Most users rated the simulation as realistic and suitable to assess cognitive skills. Novices received significantly lower (55.9±7.5) test mode scores than intermediates (80.6±4.4) (p<0.001) and experienced participants (82.3±5.3) (p<0.001). There was no significant difference in score between intermediate and experienced participants (p=0.75). Consequences evidence was provided by establishing a pass/fail score of 71% using the contrasting groups method, which resulted in one observed false positive and no false negatives. CONCLUSION A robust validity argument was constructed for the CTI test mode, which can be implemented in surgical curricula to assess learners' cognitive skills prior to hands-on simulation practice.
Collapse
Affiliation(s)
- Leander De Mol
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Joris Vangeneugden
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Liesbeth Desender
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | | | - Lars Konge
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Copenhagen, Denmark
| | - Wouter Willaert
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| |
Collapse
|
8
|
Williams J, Thelen AE, Luckoski J, Chen X, George BC. How Do Resident Surgeons Identify Operative Case Complexity? An Analysis of Resident versus Attending Perceptions. JOURNAL OF SURGICAL EDUCATION 2022; 79:469-474. [PMID: 34602380 DOI: 10.1016/j.jsurg.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/28/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Accurate recognition of patient-related complexity of an operation is critical for appropriate surgical decision making. It is not yet understood whether general surgery residents are able to accurately assess the relative complexity of a given operative case. This study investigates the agreement of case complexity ratings between residents and attending surgeons and explores whether resident-related factors correlate with any discordance in perception of patient-related operative complexity. DESIGN Residents and attending surgeons rated the relative complexity of completed cases on a 3 point scale via the SIMPL (Society for Improving Medical Professional Learning) operative assessment smartphone app. Additional trainee demographic data, autonomy ratings, and performance ratings were also obtained from the SIMPL registry for each rated case. Complexity agreement was defined as an equal rating between the resident and attending and assigned a value of zero. Over-estimate ratings were assigned a positive value and under-estimate ratings were assigned a negative value. Trends in complexity agreement were analyzed using descriptive statistics and mixed-effects models. RESULTS A total of 43,179 general surgery cases were rated by 1946 categorical general surgery residents and 1520 attending surgeons between 2015 and 2020. Residents and attendings agreed on case complexity in 63.23% of cases, while the residents overestimated complexity in 13.37% of cases and underestimated complexity in 23.40% of cases. Every level of resident except post-graduate year 2 had similar rates of agreement about the complexity of a procedure, while residents who received a higher autonomy rating were more likely to be in agreement with the faculty raters (OR 1.12, 95% CI 1.06-1.19). CONCLUSIONS The results of this study suggest that general surgery residents inaccurately perceive the patient-related complexity of a given case approximately one third of the time. Greater experience and operative autonomy appear to be associated with higher complexity agreement. Future research into factors influencing perceived case complexity may provide insight into how to best implement new teaching for surgical residents regarding the concept of case complexity.
Collapse
Affiliation(s)
- Jonathan Williams
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan.
| | - Angela E Thelen
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - John Luckoski
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - Xilin Chen
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|